Bills aimed at tackling the opioid epidemic are making their way through nearly every state legislature in the country. But as in all public health crises, without understanding the root causes of a problem all we can do is try to control the symptoms. For decades in the United States symptom-control meant incarceration, the go-to tool of the disastrous war on drugs. Having created the highest incarceration rate in the world, we hopefully have learned that we can’t punish our way out of a public health problem. More recently, the tide has turned to medication assisted treatment for people diagnosed with opioid use disorder. While I fully support making methadone and buprenorphine more accessible, I do not believe that we can treat our way of a public health problem either.

To craft good policies, we need to learn a great deal more about the root causes of opioid over-use. Gender, race and ethnicity, and class are the “big three” factors that researchers traditionally find most useful in understanding health and illness patterns in the United States.

Gender

In Massachusetts, where I conduct research, Department of Public Health data show that in 2017, 1160 males and 341 females died of opioid-related causes — nearly a four-fold difference. This enormous gender gap in opioid-related deaths does not fit the currently popular notion that (over)prescription of pain medication by doctors is the most important driver of the epidemic. In fact, women are more likely than men to present themselves as being in poor health, to visit doctors – both primary care and specialists, and to take prescription and over-the-counter medications. Women are also more likely to use prescription opioids than men, which suggests that there is no simple link between physicians’ prescribing practices and the present opioid crisis.

More relevant, decades of studies consistently show that men and especially young men die from alcohol and drug use of all sorts at substantially higher rates than women. A substantial literature attributes this gender gap to toxic notions of masculinity in general and to higher levels of risk-taking on the part of young men in particular. In order to get at the roots of the current opioid crisis it is crucial to better understand the social constructions of masculinity associated with opioid over-use as well as how opioid-related gender disparities intersect with other social patterns.

Race and Ethnicity

When we look at race and ethnicity the picture becomes even more complicated. The Massachusetts Department of Public Health data show higher rates of opioid-related deaths among whites than among other racial groups. The data also show an estimated 8.3% decline in opioid-related overdose deaths in Massachusetts in 2017 compared to 2016.

Opioid-related overdose death rate for Hispanics however, doubled over a three year period, from 15.6 per 100,000 people in 2014 to 31.4 opioid-related overdose deaths per 100,000 people in 2016. The DPH notes that these findings deserve further study. I heartily agree, and hope to see data on the gender break-down in opioid use and deaths over time for Hispanics as well as for other populations.

Class

Of the “big three” demographic factors, class may be the most complicated for Americans to understand. Our predilection to describe as “middle-class” everyone who isn’t either living in abject poverty or a multi-millionaire obscures important distinctions. While there likely is political value in describing the current opioid crisis as a problem of the “middle-class” (that is, a problem of “regular” people who deserve social support), it limits our ability to look into the conditions that characterize different kinds of “middle class” communities.
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The best source for community-level data in Massachusetts is a report on opiate-related hospital discharges by zip code produced by the Commonwealth of Massachusetts Health Policy Commission. According to that report, the per capital rate of opiate-related hospital discharges in 2015 peaked at 420 discharges in a Worcester zip code with a total population of 3888 residents, and was as low as zero in a Wellesley zip code with a total population of 1432 residents.

Examining the MHPC figures, I noticed that the communities hardest hit by the opioid crisis are not comfortably middle-class suburbs but rather poor and working class neighborhoods. Zip codes in Barnstable, Lynn, Bondsville, Hyannis, East Wareham and Holyoke are among those with the highest rates of opiate-related hospital discharges. In these communities, annual median household incomes range from $21,905 (Lynn) to $45,875 (Bondsville).  At the other end of spectrum, the zip codes with the lowest rates of opioid-related hospital discharges are among the wealthiest suburbs. The lowest rates are found in Newton, Chestnut Hill, Medfield, Wellesley, South Hamilton and Lexington where median household incomes range from $108,413 (Chestnut Hill) to $179,655 (Wellesley Hills).

Next Steps

The best data currently available indicate that opioid abuse is primarily a male problem, concentrated in working class and low income white communities, and rapidly expanding to Hispanic communities. These rather clear social patterns demand deeper investigation. What drives young men in say, Barnstable, to engage in substance abuse? What discourages young men in say, Newton Centre, from engaging in substance abuse? Why are whites and now Hispanics far more likely than African Americans to abuse opiates? And why men far more than women?

The path forward must include better and more nuanced data collection and analysis by cities, counties, states and the federal government so that we will have a clearer grasp of who is and who is not drawn into the opioid crisis.

As for me, I am launching multi-site, ethnographic case studies of several of the opioid “hot spot” communities in Massachusetts in hope of getting at the why and how of opioid problems. I plan to speak with young and old people, women and men, educators, health care providers, convenience store workers, supermarket cashiers, small business owners, pharmacy clerks, librarians, police officers, bartenders, barbers, school crossing-guards, pastors and sanitation workers; that is, with any and everyone who sees or hears what is going on in their communities. I do not know what I will find. But I do know that in order to craft sensible responses to the opioid crisis we must deepen our understanding of the root causes.

I thank my colleagues Lynn Davidman and Louellyn Lambros for their help in crafting this post.